Peter Grannum

The ultrasonic changes in the maturing placenta and their relation to fetal pulmonic maturity

A practical classification of placental maturity changes has been developed based on a review of multiple ultrasound evaluations of placental texture over a 4 year period. This classification grades placentas from 0 to 3 according to specific ultrasonic findings at the basal and chorionic plates as well as within the substance of the organ itself. The placentas of 129 patients were graded according to this system at the time of ultrasound evaluation. Eighty-six patients had placentas classified as Grade 1 or greater and all of these had lecithin-sphingomyelin (L/S) ratio determinations performed. Mature L/S ratios (2.0) were found in 68% of Grade I (21/31), 88% of Grade II (28/32), and 100% of Grade III placentas (23/23). These results suggest a correlation between maturational changes of the placenta as seen by ultrasound and fetal pulmonic maturity as indicated by L/S ratio.

Ultrasound in the diagnosis of congenital anomalies.

With high-resolution ultrasound equipment, it is now possible to diagnose certain fetal anomalies in the third trimester and in some cases before the twentieth week of gestation. During a 27 month period 2,548 ultrasound scans were performed in high-risk patients. An anomaly was diagnosed in 10 of 122 second-trimester patients who were at risk for recurrent fetal defects. Fetal deformity was also found in 26 third-trimester patients. Of the 2.8% of patients found to have polyhydramnios 18% were associated with various types of anomaly. With ultrasound it was possible to examine internal fetal anatomy and to identify abnormalities of the fetal cranium, spine, chest, abdomen, and limbs. These anomalies are reviewed here in detail. Based on ultrasonically derived information, second-trimester patients can be offered information concerning the status of their fetuses at risk genetically and physicians can better manage third-trimester patients with diagnosed fetal deformities.

In utero exchange transfusion by direct intravascular injection in severe erythroblastosis fetalis.

TRADITIONALLY, attempts to give transfusions to severely affected isoimmunized fetuses have involved the intraperitoneal injection of packed red cells.1 2 3 The success of this procedure depends on...

Assessment of fetal kidney size in normal gestation by comparison of ratio of kidney circumference to abdominal circumference

With ultrasound one can outline fetal kidneys and evaluate intrarenal anatomy. In an effort to determine how fetal kidney size varies with gestational age, 89 patients not at risk for fetal kidney disease and whose pregnancies resulted in a normal outcome were studied from 12 weeks until term. Kidney diameter measurements were taken and found to increase linearly until term. Kidney circumference (KC) measurements were made and compared to abdominal circumference (AC) measurements at the level of the umbilical vein by means of a KC/AC ratio. This ratio was found to remain constant throughout pregnancy (0.27 to 0.30). In addition, three patients at risk for congenital kidney disease were studied and the fetal kidneys were found to have KC/AC ratios approximately 6 S.D. (KC/AC ratio greater than or equal to 0.45) above the normal mean. The diagnosis was confirmed by autopsy in two cases. These data are presented for reference in evaluating patients in the second and third trimester whose fetuses are at risk for kidney abnormalities.

Percutaneous umbilical blood sampling

This report describes a technique for the performance of a sonographically guided percutaneous umbilical blood sampling and its potential uses in the management of diagnostic problems in the second and third trimester of pregnancy. The method has been employed in the prenatal assessment of 13 fetuses at risk for hemostatic failure (hemophilia and idiopathic thrombocytopenic purpura), chromosomal disorders, isoimmunization, and fetal hypoxia. This simple and rapid procedure offers access to the fetal circulation for diagnostic and therapeutic purposes.

Is routine cesarean section necessary for vertex-breech and vertex-transverse twin gestations?

Ninety-three vertex-breech and 42 vertex-transverse twin gestations were managed at Yale-New Haven Medical Center during a 5-year period. Antepartum diagnosis of twin gestation occurred in 93% of the cases, and diagnosis was made before delivery of the second twin in 97% of the cases. Seventy-two (78%) of the vertex-breech and 22 (53%) of the vertex-transverse twins were delivered vaginally. Breech extraction was used for delivery of 76 second twins. Below a birth weight of 1,500 gm, there were six neonatal deaths, four cases of documented intraventricular hemorrhage, and a 67% occurrence of depressed 5-minute Apgar scores. Above a birth weight of 1,500 gm, there were no cases of neonatal death or documented intraventricular hemorrhage and a 5% occurrence of moderately depressed 5-minute Apgar scores. Birth trauma occurred in a 3,420 gm second twin delivered by breech extraction. This infant suffered a greenstick fracture of the right clavicle and a nondisplaced fracture of the right humerus that was not associated with permanent residual injury. We think that, for birth weights greater than 1,500 gm, routine cesarean section for vertex-breech or vertex-transverse twin gestation may not be necessary.

Antenatal diagnosis of renal anomalies with ultrasound: I. Obstructive uropathy☆

During a 5-year period, a diagnosis of obstructive uropathy was made in 25 fetuses. Eight of them had unilateral obstruction and 17 were affected bilaterally. The most common condition encountered was urethral obstruction by posterior valves. The site and nature of the obstruction were correctly identified in 22 of the 25 fetuses. Among the 17 who had bilateral obstruction, only three survived. In contrast, only one infant with unilateral obstruction died (of unrelated causes). Oligohydramnios in low-level (urethral) obstruction was a uniformly lethal finding. Relief of urethral obstruction in two fetuses after 20 weeks of gestation did not result in survival of the infant, whereas shunting prior to 20 weeks in one fetus seemed to have a beneficial effect. On the basis of this experience, we suggest that unilateral obstruction would be treated best by conservative management, while in bilateral obstruction invasive treatment may be effective if initiated early in gestation, before significant oligohydramnios occurs.

The reversal of hydrops fetalis by intravascular intrauterine transfusion in severe isoimmune fetal anemia

Seventy-two intrauterine intravascular transfusions were performed on 26 patients with severe erythroblastosis fetalis. Twenty of the 26 fetuses were hydropic at the time of referral. Of the 20 hydropic fetuses, 16 (80%) survived. Hydrops was completely reversed in 13 of the 16 fetuses (81%). Total protein of less than 3 gm/dl, albumin less than 2 gm/dl, and a hematocrit level of less than 15% were associated with hydrops fetalis. After hydrops was reversed, total protein greater than 3 gm/dl, albumin greater than 2 gm/dl, along with a sustained hematocrit level of greater than 15%, were found. Only three neonates were born with minimal ascites, two of whom had had intraperitoneal transfusions before intravascular treatments. There were 21 survivors of the total group, giving an overall survival rate of 82%. There was one neonatal death from severe respiratory distress syndrome. Thirty-eight percent of the neonates did not require exchange transfusions in the newborn period. Intrauterine intravascular transfusions appear to be an effective mode of therapy in severe erythroblastosis fetalis and not only increase survival rates but also decrease neonatal morbidity and mortality.

Antenatal diagnosis of renal anomalies with ultrasound: III. Bilateral renal agenesis

Bilateral renal agenesis is a lethal congenital anomaly. A reliable prenatal diagnosis is extremely important, since it may offer options for pregnancy termination or may change obstetric management in the third trimester. This study examined the accuracy of ultrasound in making an antenatal diagnosis of bilateral renal agenesis in three different populations: (1) patients with a family history of bilateral renal agenesis, (2) patients diagnosed during the course of a routine scan, and (3) patients referred because of a previous suspicious ultrasound examination in a level I ultrasound facility. In group A there were three true positive, 13 true negative, no false negative, and no false positive diagnoses. In group B there were three true positive and no false positive diagnoses. In group C there were 12 true positive, 17 true negative, one false negative, and no false positive diagnoses. The value and potential pitfall of the different diagnostic criteria are discussed. We conclude that ultrasound is a valuable tool in the detection of intrauterine renal failure, although there are limitations to a specific diagnosis of bilateral renal agenesis.

Pulsed Doppler flow-velocity waveforms before and after intrauterine intravascular transfusion for severe erythroblastosis fetalis

Abstract Pulsed Doppler studies of the fetal and maternal circulations were carried out before and after 64 intrauterine transfusions performed on 24 fetuses. A model was derived for the prediction of hematocrit before the first transfusion: Hematocrit=7.778 − (0.088 × peak velocity in descending aorta) + (0.968 × gestational age [weeks]) − (10.911 if hydrops present) ( r = 0.876, p r = 0.822, p r = 0.81, p